New Zealand / Waikato

Coroner highlights lack of adequate care prior to man's death

09:52 am on 30 July 2018

A coroner has found that a Waikato man who died of heart failure didn't get proper care before his death.

The caravan where Gerald Gotty was staying had an "unrepaired broken window, limited warmth, with minimal bedding," the coroner said. Stock photo. Photo: 123RF

Gerald Gotty, 60, died in September 2014 from heart failure but also suffered a number of physical and mental health issues, including schizophrenia.

Up until August 2013, Mr Gotty was subject to full-time care under the Mental Health Act.

He moved into a caravan on his brother's property the following month and was subject to supervision and compulsory treatment from a district mental health nurse.

Coroner Michael Robb said Mr Gotty was described as "fiercely independent", likely in part due to his mental health condition, which on occasion made him difficult to care for.

He also consumed alcohol and drugs, which Mr Robb said could have contributed to him developing bronchial pneumonia.

Because Mr Gotty could become difficult to care for, other family members would step in to help. A cousin, Marshall Gotty, who tried to care for Mr Gotty also struggled. He sought help from mental health services but he never completed the paperwork and no extra assistance was given.

In August 2014, another cousin visited Mr Gotty and noticed he had a black eye and Marshall Gotty admitted to hitting Mr Gotty after he refused to take his required medication for schizophrenia. He was taken to hospital to get his eye treated.

It was family members who raised concerns about Mr Gotty's health with the mental health nurse.

When the nurse visited, Mr Gotty was found sleeping in a car which he explained was warmer than the caravan he was living in.

The caravan had an "unrepaired broken window, limited warmth, with minimal bedding," Mr Robb said.

The nurse planned to check up again on Mr Gotty the following day.

But the nurse who cared for 50 patients, more than double the ideal workload, was called out to an emergency that day and could not visit Mr Gotty until three days later on 25 August.

Mr Gotty was found cold and unresponsive in his bed and his cousin Marshall wasn't at the property.

He was transferred to Taumaranui Hospital "where it was found that his core body temperature was so low that no reading was able to be obtained".

Mr Gotty was treated for hypothermia at Waikato Hospital but despite being considered well enough to go home on 14 September, he died a day later.

The post-mortem revealed that Mr Gotty had died from alcohol-related heart-failure but acute bronchial pneumonia and septicaemia were contributing factors.

Mr Robb found Mr Gotty died of heart failure that was aggravated by inadequate care before he was admitted to hospital.

Marshall Gotty was prosecuted for striking Mr Gotty and failing to provide the necessities of life to a vulnerable person, to which he pleaded guilty and was both convicted and sentenced.

The coroner said because of the prosecution, he makes no additional recommendation or comment in respect of Mr Gotty's death.

But Mr Robb said the medical conditions that contributed to Mr Gotty's death were caused and/or aggravated by the lack of adequate care provided to him before he reached hospital.